12 Month follow-up survey of impact study participants

Form Approved

OMB No: 0990-0424
Exp Date: xx/xx/20xx

Positive Adolescent Futures

DRAFT 12 MONTH FOLLOW-UP SURVEY - California

PRIVACY Thank you for your help with this important study. It will help us understand what things are like for people your age today and help to identify effective ways to improve the health of youth. This survey includes questions about your family, community, future goals, and also your attitudes and behaviors. Your answers and everything you say will be kept private. Your name will not be on the survey. Please answer all questions as well as you can. We want you to know that: 1. Your participation in this survey is voluntary. 2 We hope that you will answer all the questions, but you may skip any questions you do not wish to answer. 3. The answers you give will be kept private. Your responses will be combined with those of other people your age. Mathematica Policy Research

THE PAPERWORK REDUCTION ACT OF 1995 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0424. The time required to complete this information collection is estimated to average 35 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

SECTION 1: BACKGROUND INFORMATION (Education and employment)

SECONDARY OR POSTSECONDARY EDUCATION OUTCOMES

1.1. Are you currently enrolled in any type of school or education program? If you are currently on summer vacation or taking a short break to have your baby but plan to return to school, please answer “yes.” (BL 1.4)

YES 1

NO 0 GO TO 1.3

DON’T KNOW d GO TO 1.3

REFUSED r GO TO 1.3

1.2. In what type of school or education program are you currently enrolled? Would you say…(BL 1.5)

Middle school, 1 GO TO 1.4

High school, 2 GO TO 1.4

A GED education program, 3 GO TO 1.4

A vocational tech program, 4 GO TO 1.4

Two-year community college, or 5 GO TO 1.4

four-year community college? 6 GO TO 1.4

DON’T KNOW d GO TO 1.4

REFUSED r GO TO 1.4

1.3. Are you enrolled in a GED program or a post high school vocational training program? (BL 1.6)

INTERVIEWER: If they only say yes, use probe below

PROBE: Is that a GED program or is it a post high school vocational training program?

YES, A GED EDUCATION PROGRAM 1

YES, A VOCATIONAL TRAINING PROGRAM (POST HIGH SCHOOL) 2

NO 0

DON’T KNOW d

REFUSED r

1.4. What is the highest grade you have finished? For example, if you are in 9th grade now, but have not finished the school year, select 8th grade. (BL 1.7)

INTERVIEWER: (if they say any amount of two or four year college) Thinking back to high school, what was the highest grade you completed?

LESS THAN 7TH GRADE 1

7TH GRADE 2

8TH GRADE 3

9TH GRADE 4

10TH GRADE 5

11TH GRADE 6

12TH GRADE 7

DON’T KNOW d

REFUSED r

1.5. Do you have any of these degrees or certificates? (BL 1.8)

	YES	NO
a. A high school diploma	1	0
b. A GED	1	0
c. A certificate or license, for example, from a vocational training program	1	0
d. An associate’s degree from a two-year college or community college	1	0
e. A bachelor’s degree from a four-year college	1	0

1.6. On your last report card, what kind of grades did you get? If you are not currently attending school, answer based on the last school you attended. (BL 1.10)

INTERVIEWER: due to the pattern within the response options, If they answer before all choices read, it is ok to code the response and go to the next question.

Mostly As, 1

About half As and half Bs, 2

Mostly Bs, 3

About half Bs and half Cs, 4

Mostly Cs, 5

About half Cs and half Ds, 6

Mostly Ds, 7

About half Ds and half Fs, or 8

Mostly Fs? 9

DON’T KNOW d

REFUSED r

1.7. What is the highest level of education that you think you will complete? (BL 1.15)

Less than high school, that is, you don’t think you will graduate or get a GED, 1

A high school diploma or GED, 2

A technical or trade school certificate or industry certification, 3

An associate’s degree from a two-year college or community college, 4

A bachelor’s degree from a four-year college, or 5

A master’s degree, doctorate or other advanced degree? 6

DON’T KNOW d

REFUSED r

1.8. Are you currently working at a full or part-time job or jobs? (Chafee E.1)

YES 1 GO TO 1.10

NO 0

DON’T KNOW d

REFUSED r

1.9. Have you been employed in the past 12 months? (Chafee E.2)

YES 1

NO 0

DON’T KNOW d

REFUSED r

Next please answer some questions about how you feel about yourself and your future.

1.10. How much do you agree or disagree with the following statements? (New)

	STRONGLY DISAGREE	DISAGREE	AGREE	STRONGLY AGREE
a. I have a positive attitude about myself	1	2	3	4
b. I am aware of my personal strengths	1	2	3	4
c. I use my strengths to solve my problems	1	2	3	4
d. My belief in myself gets me through hard times	1	2	3	4
e. I often feel that there is little I can do to change what happens to me	1	2	3	4
f. I usually make quick decisions based on what feels right in the moment	1	2	3	4
g. When I have a serious disagreement with someone I can talk calmly about it without losing control	1	2	3	4
h. I do what I think is right even if it is different than what others around me are doing	1	2	3	4
i. I can resist doing something when I know that I shouldn’t do it	1	2	3	4
j. I keep my mind open to different ideas when making decisions	1	2	3	4
k. I can get through difficult times because I’ve experienced difficulty before	1	2	3	4
l. There are things I do that help make my community (including family, school, neighborhood or church) better	1	2	3	4
m. My life has meaning	1	2	3	4

The next questions focus on how you feel about your goals

1.11. How much do you agree or disagree with the following statements? (BL 1.16)

	STRONGLY DISAGREE	DISAGREE	AGREE	STRONGLY AGREE
a. I am focused on preventing negative things from happening in my life	1	2	3	4
b. I set goals and think about what I need to do to reach those goals	1	2	3	4
c. When faced with a problem, I can usually find a solution	1	2	3	4
d. I think going to college is important for getting a good job	1	2	3	4
e. I am focused on achieving good and positive things in my life	1	2	3	4
f. I have a plan for achieving my future education or career goals	1	2	3	4
g. I don’t like to plan too far ahead because things don’t usually go the way I planned	1	2	3	4
h. I have opportunities that are challenging and interesting	1	2	3	4

The next questions focus on how others may help you.

1.12. How much do you agree or disagree with the following statements? (BL 2.11-revised)

	STRONGLY DISAGREE	DISAGREE	AGREE	STRONGLY AGREE
a. There is an adult who I can count on when things go wrong	1	2	3	4
b. There is an adult who helps me make good decisions	1	2	3	4
c. There is an adult who encourages me to do my best	1	2	3	4
d. There is an adult in my life who supports me with the plans and goals I have for my future .	1	2	3	4
e. I know where to go to get support for the things I need	1	2	3	4
f. I express my ideas, concerns, and opinions with important people in my life (such as family, partner, or friend)	1	2	3	4

SECTION 2: SERVICES RECEIVED

INTRO: In the following questions we will be asking questions about services you may have received from your [PROGRAM NAME] case manager, at somewhere recommended by that case manager, or somewhere else. (New)

2.1. In the past 12 months, did you attend any classes or sessions (individual or group) about the following?
(BL 4.1-revised)

	YES	NO
a. Relationships, dating, or marriage	1	0
b. Parenting or how to care for your baby	1	0
c. How to get health insurance or apply for Medicaid for your baby	1	0
d. Where to get healthcare for your baby	1	0
e. How to get childcare for your baby	1	0
f. How to get health insurance or apply for Medicaid for yourself	1	0
g. Where to get healthcare for yourself	1	0
h. Where to get food assistance and support for yourself and your baby	1	0
i. Where to find affordable housing	1	0
j. Where to get counseling or treatment for depression or anxiety	1	0

DISPLAY 2.2 FOLLOW UP AFTER EACH YES RESPONSE AT 2.1

2.2. Did these classes or sessions take place with your case manager from [PROGRAM SITE], at somewhere recommended by your case manager, or somewhere else? (New)

	CASE MANAGER	RECOMMENDED BY CASE MANAGER	SOMEWHERE ELSE
a. Relationships, dating, or marriage	1	2	3
b. Parenting or how to care for your baby	1	2	3
c. How to get health insurance or apply for Medicaid for your baby	1	2	3
d. Where to get healthcare for your baby	1	2	3
e. How to get childcare for your baby	1	2	3
f. How to get health insurance or apply for Medicaid for yourself	1	2	3
g. Where to get healthcare for yourself	1	2	3
h. Where to get food assistance and support for yourself and your baby	1	2	3
i. Where to find affordable housing	1	2	3
j. Where to get counseling or treatment for depression or anxiety	1	2	3

2.3. In the past 12 months, have you participated in any of the following education related services? (BL 4.3)

	YES	NO
a. GED preparation	1	0
b. Tutoring or outside help with school work	1	0
c. Programs to prepare for a high school diploma	1	0
d. Standardized achievement test preparation for state or local tests	1	0
e. College preparation activities such as college awareness or college guidance activities, college preparation or transition programs, or preparing for college entrance examinations or college applications	1	0
f. Getting help finding financial aid	1	0
g. Another education related service (SPECIFY)	1	0

DISPLAY 2.4 FOLLOW UP AFTER EACH YES RESPONSE AT 2.3

2.4. And did you receive these education related services from your case manager at [PROGRAM SITE], at somewhere recommended by your case manager, or somehwere else?(New)

	CASE MANAGER	RECOMMENDED BY CASE MANAGER	SOMEWHERE ELSE
a. GED preparation	1	2	3
b. Tutoring or outside help with school work	1	2	3
c. Programs to prepare for a high school diploma	1	2	3
d. Standardized achievement test preparation for state or local tests	1	2	3
e. College preparation activities such as college awareness or college guidance activities, college preparation or transition programs, or preparing for college entrance examinations or college applications	1	2	3
f. Getting help finding financial aid	1	2	3
g. Another education related service (SPECIFY)	1	2	3

2.5. In the past 12 months, have you participated in any of the following training or job related services? (BL 4.5)

	YES	NO
a. Career counseling	1	0
b. Help finding or applying for a job training program	1	0
c. Job training	1	0
d. Help looking for or applying for a job	1	0
e. Another training or job related service (SPECIFY)	1	0

DISPLAY 2.6 FOLLOW UP AFTER EACH YES RESPONSE AT 2.5

2.6. And did you receive these training or job related services from your case manager at [PROGRAM SITE], at somewhere recommended by your case manager, or somewhere else? (New)

	CASE MANAGER	RECOMMENDED BY CASE MANAGER	SOMEWHERE ELSE
a. Career counseling	1	2	3
b. Help finding or applying for a job training program	1	2	3
c. Job training	1	2	3
d. Help looking for or applying for a job	1	2	3
e. Another training or job related service (SPECIFY)	1	2	3

SECTION 3: ALCOHOL AND DRUG USE

3.1. Some of the things listed below might happen to people. Please tell us if any of these things happened to you in the past 12 months? (BL 3.8 -revised)

	YES	NO
a. Someone in my family or I went hungry because we could not afford enough food	1	0
b. Someone in my family or I didn’t have enough money for housing	1	0
c. I got in trouble with the law, or went to jail	1	0
d. The person I am currently in a relationship with got in trouble with the law or went to jail	1	0
e. A parent, guardian or other adult I lived with (not including the person I am currently in a relationship with), got in trouble with the law or went to jail	1	0
f. I was placed in foster care (removed from my home by the court or child welfare agency)	1	0
g. I saw or heard my parents, guardians, or other adults in my home slap, hit, kick, punch, or beat each other up	1	0
h. A parent, guardian or other adult I lived with had a serious drinking or drug problem	1	0
i. A parent, guardian, or other adult I lived with was mentally ill or suicidal, or severely depressed for more than a couple of weeks	1	0
j. A child of mine was placed in foster care (removed from my home by the court or child welfare agency)	1	0

3.2. The next questions are about alcohol, drugs and general health. Please be as honest as possible, and remember that your answers will be kept private and will not be shared with anyone. (BL 3.1)

During the past 30 days, on how many days did you smoke one or more cigarettes?

PROBE: (if having trouble) Your best estimate is fine.

0 DAYS 1

1 OR 2 DAYS 2

3 TO 5 DAYS 3

6 TO 9 DAYS 4

10 TO 19 DAYS 5

20 TO 29 DAYS 6

ALL 30 DAYS 7

DON’T KNOW d

REFUSED r

3.3. The next two questions ask about drinking alcohol. This includes drinking beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. For these questions, drinking alcohol does not include drinking a few sips of wine for religious purposes.

During the past 30 days, on how many days did you have at least one drink of alcohol? (BL3.2)

PROBE: (if having trouble) Your best estimate is fine.

0 DAYS 1 GO TO 3.5

1 OR 2 DAYS 2

3 TO 5 DAYS 3

6 TO 9 DAYS 4

10 TO 19 DAYS 5

20 TO 29 DAYS 6

ALL 30 DAYS 7

DON’T KNOW d

REFUSED r

3.4. During the past 30 days, on how many days did you have 5 or more drinks in a row, that is, within a couple hours? (BL 3.3)

PROBE: (if having trouble) Your best estimate is fine.

0 DAYS 1

1 OR 2 DAYS 2

3 TO 5 DAYS 3

6 TO 9 DAYS 4

10 TO 19 DAYS 5

20 TO 29 DAYS 6

ALL 30 DAYS 7

DON’T KNOW d

REFUSED r

3.5. During the past 30 days, on how many days did you use marijuana, also called weed or pot? (BL 3.4)

PROBE: (if having trouble) Your best estimate is fine.

0 DAYS 1

1 OR 2 DAYS 2

3 TO 9 DAYS 3

10 TO 19 DAYS 4

20 OR MORE DAYS 5

DON’T KNOW d

REFUSED r

3.6. During the past 30 days, on how many days did you use any other type of illegal drug, inhalant, or a prescription drug in a way that was not prescribed? (BL 3.5)

PROBE: (if having trouble) Your best estimate is fine.

0 DAYS 1

1 OR 2 DAYS 2

3 TO 5 DAYS 3

6 TO 9 DAYS 4

10 TO 19 DAYS 5

20 TO 29 DAYS 6

ALL 30 DAYS 7

DON’T KNOW d

REFUSED r

3.7. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities? (BL 3.6)

YES 1

NO 0

DON’T KNOW d

REFUSED r

SECTION 4: CONTRACEPTIVE KNOWLEDGE AND INFORMATION

4.1. Below are several statements about condoms. Please mark whether you think each statement is true, false, or you don’t know. (BL 5.1)

	TRUE	FALSE	DON’T KNOW
a. It is okay to use the same condom more than once	1	2	d
b. Condoms have an expiration date	1	2	d
c. When putting on a condom, it is important to leave a space at the tip	1	2	d
d. It is okay to use petroleum jelly or Vaseline as a lubricant when using latex condoms	1	2	d
e. When using a condom, it is important for the man to pull out right after ejaculation	1	2	d
f. Wearing two latex condoms will provide extra protection	1	2	d

4.2. Below are several statements about birth control pills. Please mark whether you think each statement is true, false, or you don’t know. (BL 5.2)

	TRUE	FALSE	DON’T KNOW
a. Birth control pills are effective, even if a woman misses taking them for two or three days in a row	1	2	d
b. Women should “take a break” from the pills every couple of years	1	2	d
c. After a woman stops taking birth control pills, she is unable to get pregnant for at least two months	1	2	d
d. In order to get the birth control pill, a woman must have a pelvic exam	1	2	d
e. Birth control pills can reduce risk of getting a sexually transmitted disease or STD	1	2	d

4.3. Below are several statements about IUDs (such as Mirena, ParaGard, or Skyla). Please mark whether you think each statement is true, false, or you don’t know. (BL 5.3)

	TRUE	FALSE	DON’T KNOW
a. Women who use IUDs cannot use tampons	1	2	d
b. A woman can get an IUD without going to a doctor’s office, clinic or medical professional	1	2	d
c. An IUD cannot be felt by a woman’s partner during sex	1	2	d
d. IUDs can move around in a woman’s body	1	2	d
e. An IUD is effective (prevents pregnancy) for at least 3 years	1	2	d
f. Using an IUD will cause weight gain	1	2	d

4.4. Below are some statements about other forms of birth control. Please mark whether you think each statement is true, false, or you don’t know. (BL 5.4)

	TRUE	FALSE	DON’T KNOW
a. Women using the birth control shot, Depo-Provera, must get an injection about every 3 months	1	2	d
b. Even if a woman is late getting her birth control shot, she is still protected from pregnancy for at least 3 months	1	2	d
c. Women using the vaginal ring, or NuvaRing, must have it inserted by a doctor or health care provider every month	1	2	d
d. Long-acting methods like the implant (Implanon or Nexplanon) or an IUD (Mirena, ParaGard, or Skyla) cannot be removed early, even if a woman changes her mind about wanting to get pregnant	1	2	d
e. Long-acting methods like the implant (Implanon or Nexplanon) or an IUD (Mirena, ParaGard, or Skyla) can make it more difficult to become pregnant in the future when a woman is no longer using them	1	2	d

4.5. In the past 12 months, did you receive information from a doctor, nurse, case manager, or clinic about any of the following? (BL 5.5)

	YES	NO
a. Methods of birth control, such as condoms, birth control pills, the patch, the shot, the ring, IUD, or an implant	1	0
b. Where to get birth control	1	0
c. Sexually transmitted diseases, also known as STDs or STIs	1	0

4.6. In the past 12 months, did you get any type of birth control from a doctor, nurse, case manager, or clinic, such as condoms, birth control pills, the patch, the shot, the ring, IUD, an implant? (BL 5.6)

YES 1

NO 0

DON’T KNOW d

REFUSED r

SECTION 5: FAMILY AND RELATIONSHIPS

5.1. Now I would like to ask you some questions about children. Our records show that you [had/were expecting to have] a baby on [DATE OF BIRTH / DUE DATE]. Is that the date the baby was born? (HFSA 5.5)

YES 1 GO TO 5.3

YES, BUT THE BABY DIED 2 GO TO 5.11

NO, BABY WAS BORN ON A DIFFERENT DATE 3 GO TO 5.2

NO, MISCARRIAGE 4 GO TO 5.11

NO, THE BABY DIED 5 GO TO 5.11

DON’T KNOW d GO TO 5.2

REFUSED r GO TO 5.2

5.2. On what date was the baby born? (HFSA 5.6)

| | | / | | | / | | | | |

MONTH DAY YEAR

DON’T KNOW d

REFUSED r

5.3. So I can refer to the baby, what is the baby’s first name? (HFSA 5.7)

INTERVIEWER: IF SHE HAD A MULTIPLE BIRTH, TAKE NAME OF FIRST BORN.

BABY’S NAME

DON’T KNOW d

REFUSED r

5.4. INTERVIEWER: DO NOT ASK IF ALREADY KNOW

Is [CHILD] male of female? (HFSA 5.8)

MALE 1

FEMALE 2

DON’T KNOW d

REFUSED r

5.5. Did you ever breastfeed or pump breast milk to feed [CHILD] after delivery, even for a short period of time? (PRAMS – Core - 45)

YES 1

NO 0 GO TO 5.8

DON’T KNOW d GO TO 5.8

REFUSED r GO TO 5.8

5.6. Are you currently breastfeeding or feeding pumped breast milk to [CHILD]? (PRAMS – Core 46)

YES 1 GO TO 5.8

NO 0

DON’T KNOW d

REFUSED r

5.7. How old was [CHILD] when you stopped breastfeeding or giving (him/her) pumped breast milk? (New)

| | | number

weeks 1

months 2

Less than 1 week 3

DON’T KNOW d

REFUSED r

5.8. During the past 12 months, did [CHILD] see a doctor, nurse, or other health care professional for any kind of medical care, including sick child care, well child checkups, physical exams, and hospitalizations? (NSCH-2011 S4Q01)

YES 1

NO 0 GO TO 5.10

DON’T KNOW d

REFUSED r

5.9. During the past 12 months, how many times did [CHILD] see a doctor, nurse, or other health care provider for a regular checkup, not a sick child care visit or hospitalization? Your best estimate is fine. (NSCH-2011 K4Q20-revised)

| | | number OF TIMES

DON’T KNOW/CAN’T REMEMBER d

REFUSED r

5.10. Has [CHILD] been seen by a doctor or nurse as many times as you wanted when (he/she) was sick? (PRAMS – Standard - T3 revised)

YES 1

NO 0

DON’T KNOW d

REFUSED r

5.11. THE TEXT THAT WEB/INTERVIEWERS USE FOR THE NEXT FEW QUESTIONS IS DEPENDENT ON THE RESPONDENT’S ANSWERS TO STATUS OF BABY 5.1

THE BABY WAS BORN EITHER ON REPORTED DATE OR DIFFERENT DATE (5.1 = 1 or 3): In the 3 months after you had [CHILD] , did you have a checkup with a doctor, nurse, or other health care worker for yourself? (New)

THE BABY DIED (5.1 =2 or 5): Since the loss of your baby, have you had a checkup with a doctor, nurse, or other health care worker for yourself?

A MISCARRIAGE (5.1 = 4): Since your miscarriage, have you had a checkup with a doctor, nurse, or other health care worker for yourself?

YES 1

NO 0

DON’T KNOW d

REFUSED r

5.12. THE TEXT THAT WEB/INTERVIEWERS USE FOR THE NEXT FEW QUESTIONS IS DEPENDENT ON THE RESPONDENT’S ANSWERS TO STATUS OF BABY 5.1

THE BABY WAS BORN EITHER ON REPORTED DATE OR DIFFERENT DATE (5.1 = 1 or 3): Since [CHILD] was born, have you asked for help for depression from a doctor, nurse, or other health care worker? (PRAMS – Standard - M6)

THE BABY DIED (5.1 =2 or 5): Since the loss of your baby, have you asked for help for depression from a doctor, nurse, or other health care worker?

A MISCARRIAGE (5.1 = 4): Since your miscarriage, have you asked for help for depression from a doctor, nurse, or other health care worker?

YES 1

NO 0

DON’T KNOW d

REFUSED r

The next questions are about health insurance. This can include private insurance, Medicaid, MediCal, or any other government program that pays for medical care.

5.13. INTERVIEWER: SKIP IF BABY DIED 5.1 = 2, 4, OR 5

Do you have health insurance for [CHILD]? (new)

YES 1

NO 0

DON’T KNOW d

REFUSED r

5.14. Do you have health insurance for yourself? (New)

YES 1

NO 0

DON’T KNOW d

REFUSED r

INTERVIEWER: IF BABY DIED 5.1 = 2, 4, OR 5 SKIP TO 5.20

Next, please think about where you and [CHILD] live…

5.15. Do you currently live with [CHILD] in the same household…(HFSA 5.9)

All of the time, 1 GO TO 5.18

Most of the time, 2

Some of the time, or 3

None of the time? 4

DON’T KNOW d

REFUSED r

5.16. Have you seen [CHILD] in the past month? (HFSA 5.10)

YES 1

NO 0

DON’T KNOW d

REFUSED r

5.17. [IF 5.15 = MOST OR SOME]: When [CHILD] is not living with you,

[IF 5.15=NONE]: (W/w)ho does [CHILD] live with? (HFSA 5.11)

Father, 1

Grandparent/s, 2

Other relative/s, 3

Adoptive parent/s, 4

Foster parent/s, or 5

Someone else? (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

5.18. Since [CHILD] was born, have you lived with [CHILD] in the same household (New)

All of the time,………………………………………………………………………………1 GO TO 5.19

Some if the time, or...………………………………………………………………………2

None of the time?.......................................................................................................3 GO TO 5.19

INTERVIEWER: IF 5.18=2 ASK 5.18a

5.18a Since [CHILD] was born, how many months have you lived with [CHILD] in the same household?

INTERVIEWER, IF STRUGGLING: If your child has lived with you on and off since [his/her] birth, please count the total number of months.

| | | number of months

DON’T KNOW d

REFUSED r

5.19. INTERVIEWER: SKIP IF 5.16 = NO

The next questions are about things YOU may have done with [CHILD] in the past month.

In the past month, how often have you done each of the following? Was it every day or almost every day, a few times a week, a few times in the past month, or never in the past month? (HFSA 5.13-revised)

	EVERY DAY OR ALMOST EVERY DAY	A FEW TIMES A WEEK	A FEW TIMES IN THE PAST MONTH	NEVER IN THE PAST MONTH
a. Played games like “peek-a-boo” or “gotcha” with [CHILD]	3	2	1	0
b. Sung songs with [CHILD]	3	2	1	0
c. Read or looked at books with [CHILD]	3	2	1	0
d. Played outside or at the playground with [CHILD]	3	2	1	0
e. Played with games or toys with [CHILD]	3	2	1	0

PARENTING AND CO-PARENTING SKILLS

5.20. How much do you agree or disagree with the following statements about romantic/sexual relationships? (BL 2.14)

	STRONGLY DISAGREE	DISAGREE	AGREE	STRONGLY AGREE
a. In a good relationship, you don’t always get your own way	1	2	3	4
b. There are times when hitting or pushing is okay in a relationship	1	2	3	4
c. A good relationship is based on mutual respect, not just sex	1	2	3	4
d. People who make their partner jealous deserve to be hit or pushed	1	2	3	4
e. It would be easy to trust your partner, even when you’re apart	1	2	3	4
f. Avoiding a disagreement with your partner is always better than talking about your problem	1	2	3	4

5.21. The next questions are about your relationship with [CHILD]’s father.

Do you live with him? (BL 2.15)

VOLUNTEERED – FATHER OF THE BABY DIED – GO TO 6.1

None of the time, 1

Some of the time, or 2

All of the time? 3

DON’T KNOW d

REFUSED r

5.22. How would you define your current relationship status with [CHILD]’s father? (BL 2.16)

Married to each other, 1

In a serious romantic relationship, 2

In a casual romantic relationship, 3

Not currently in a romantic relationship, but in regular contact, or 4

No longer in regular contact? 5

DON’T KNOW d

REFUSED r

5.23. Taking all things together, on a scale from 0 to 10, where 0 is not at all happy and 10 is completely happy, how happy would you say your relationship with [CHILD]’s father is? You can choose any number from 0 to 10. (HFSA 5.18)

NOT AT ALL HAPPY

COMPLETELY HAPPY

0 1 2 3 4 5 6 7 8 9 10

DON’T KNOW d

REFUSED r

5.24. How often do you and [CHILD]’s father see or talk to each other? Is it… (HFSA 5.20)

Every day or almost every day, 1

A few times a week, 2

A few times a month, 3

About once a month, 4

A few times in the past year, or 5

Hardly ever or never? 6

DON’T KNOW d

REFUSED r

5.25. INTERVIEWER: SKIP IF 5.18 = 3 OR IF BABY DIED 5.1 = 2, 4, OR 5

You mentioned that since [CHILD] was born, you have [if 5.18=1, always] lived in the same household with [CHILD] [if 5.18=2, fill months from 5.18a,for [NUMBER OF MONTHS] months]. Since [CHILD] was born, have you lived with [CHILD] and [CHILD]’s father in the same household (New)

All of the time,………………………………………………………………………………………1 GO TO 5.26

Some of the time……………………………………………………………………………………2

None of the time?..................................................................................................................3 GO TO 5.26

5.25a Since [CHILD] was born, how many months have you lived in the same household with both [CHILD] and [CHILD]’s father? (HFSA 5.21-revised)

| | | NUMBER OF MONTHS

DON’T KNOW d

REFUSED r

5.26. INTERVIEWER: SKIP IF BABY DIED (5.1 = 2,4 OR 5)

The next question is about time [CHILD]’s father spends with [CHILD].

In the past month, how often has [CHILD]’s father spent one or more hours a day with [CHILD]? Was it… (HFSA 5.22)

Every day or almost every day, 1

A few times a week, 2

A few times in the past month, 3

Once or twice in the past month, or 4

Never? 5

DON’T KNOW d

REFUSED r

SECTION 6: HEALTH AND SEXUAL BEHAVIOR

6.1. In the past 12 months, have you been sexually active? (BL 6.6)

YES 1

NO 0 GO TO 6.7

DON’T KNOW d GO TO 6.7

REFUSED r GO TO 6.7

6.2. In the past 12 months, how many DIFFERENT PEOPLE have you ever had sexual intercourse with, even if only one time? (HFSA 4.1)

| | | NUMBER OF PEOPLE

DON’T KNOW d

REFUSED r

6.3. In the past 12 months, did you ever have sexual intercourse without using birth control, such as condoms, birth control pills, the patch, the shot, the ring, an IUD, or an implant? (BL 6.7)

YES 1

NO 0 GO TO 6.5

DON’T KNOW d GO TO 6.5

REFUSED r GO TO 6.5

6.4. The next question is about your use of the following methods of birth control:

• Condoms

• Birth control pills

• The shot (Depo-Provera)

• The patch (Ortho Evra)

• The ring (NuvaRing)

• IUD (Mirena, ParaGard, or Skyla)

• Implant (Implanon or Nexplanon)

In the past 12 months, how many TIMES did you have sexual intercourse without using any of these methods of birth control? (BL 6.9)

Your best estimate is fine.

| | | | NUMBER OF TIMES

DON’T KNOW d

REFUSED r

6.5. In the past 12 months, did you use any of the following types of birth control… (HFSA 5.2)

	YES	NO
a. Condoms?	1	0
b. Birth control pills?	1	0
c. The patch, such as Ortho Evra ?	1	0
d. The shot, such as Depo-Provera or other injectable birth control?	1	0
e. The ring, such as NuvaRing?	1	0
f. An IUD, such as Mirena, ParaGard, or Skyla?	1	0
g. An implant, such as Implanon or Nexplanon?	1	0
h. Another type of birth control? (SPECIFY)	1	0

6.6. INTERVIEWER: FOR ALL BIRTH CONTROL METHODS LISTED IN THE PREVIOUS QUESTION TO WHICH THE RESPONDENT ANSWERED “YES”, ASK THIS QUESTION.

Are you currently using … (HFSA 5.3)

	YES	NO
a. Condoms?	1	0
b. Birth control pills?	1	0
c. The patch, such as Ortho Evra?	1	0
d. The shot, such as Depo-Provera or other injectable birth control?	1	0
e. The ring, such as NuvaRing?	1	0
f. An IUD, such as Mirena, ParaGard, or Skyla?	1	0
g. An implant, such as Implanon or Nexplanon?	1	0
h. [THE TYPE OF BIRTH CONTROL MENTIONED IN 6.5h]	1	0

6.7. THE TEXT THAT WEB/INTERVIEWERS USE FOR THE NEXT FEW QUESTIONS IS DEPENDENT ON THE RESPONDENT’S ANSWERS TO STATUS OF BABY 5.1

THE BABY WAS BORN EITHER ON REPORTED DATE OR DIFFERENT DATE (5.1 = 1 or 3): The next few questions are about pregnancy. Since [CHILD’S NAME] was born, have you been pregnant? (HFSA 5.27)

THE BABY DIED (5.1 =2 or 5): The next few questions are about pregnancy. Since the baby that died, have you been pregnant?

A MISCARRIAGE (5.1 = 4): The next few questions are about pregnancy. Since the miscarriage, have you been pregnant?

YES 1

NO 0 GO TO 6.13

DON’T KNOW d GO TO 6.13

REFUSED r GO TO 6.13

6.8. IF RESPONDENT REPORTED THAT THE BABY DIED OR SHE HAD A MISCARRIAGE (5.1= 2 or 4 or 5): How many times have you been pregnant since then, even if no baby was born? If you are currently pregnant, please include your current pregnancy. (HFSA 5.28)

OTHERWISE: Since [CHILD] was born, how many times have you been pregnant, even if no baby has been born? If you are currently pregnant, please include your current pregnancy.

| | | NUMBER OF TIMES

DON’T KNOW d

REFUSED r

6.9. Are you currently pregnant? (HFSA 5.29)

YES 1

NO 0 GO TO 6.11

DON’T KNOW d GO TO 6.11

REFUSED r GO TO 6.11

6.10. What is the baby’s due date? (HFSA 5.30)

| | | / | | | / | | | | |

MONTH DAY YEAR

DON’T KNOW d

REFUSED r

6.11. INTERVIEWER: Skip if 6.8=1 and 6.9=Yes

IF BABY DIED (5.1 =2 or 5): Since the baby that died, have you had another baby? (HFSA 5.31)

IF RESPONDENT REPORTED MISCARRIAGE (5.1 = 4): Since the miscarriage, have you had another baby?

OTHERWISE: Since [CHILD] was born, have you had another baby?

YES 1

NO 0 GO TO 6.13

DON’T KNOW d GO TO 6.13

REFUSED r GO TO 6.13

6.12. When was your most recent baby born? (HFSA 5.33)

| | | / | | | / | | | | |

MONTH DAY YEAR

DON’T KNOW d

REFUSED r

6.13. [IF 6.9=1 FILL “After your current pregnancy”]Do you ever want to have any more children? (HFSA 5.35-revised)

YES 1

NO 0 GO TO THANK YOU

DON’T KNOW d GO TO THANK YOU

REFUSED r GO TO THANK YOU

6.14. How soon would you like to have your next child? Would you like to have it… (HFSA 5.36)

Within the next year, 1

One year from now, 2

Two years from now, 3

Three years from now, or 4

Four or more years from now?.................................................................................5

DON’T KNOW d

REFUSED r

Thank you for completing this survey!